University of Michigan Health System

Program and Operations Analysis

Analysis of Afternoon Shift Staffing Needs in Central Sterile Supply

Final Report

To: Karen Bett, Central Sterile Supply Manager

Sheri Curnes, Senior Management Engineer — Program and Operations Analysis

Richard I. Coffey, Director — Program and Operations Analysis

From: IOE 481 Project Team — Program and Operations Analysis

Alexander Johnson

Jake Koppinger

Natalie Levy

David Ollinger

Date: April 20, 2006

Table of Contents

SectionPage

EXECUTIVE SUMMARY 3

INTRODUCTION 5

GOALS AND OBJECTIVES 5

BACKGROUND 5

Key Issues 6

Project Scope 6

PROJECT APPROACH AND FINDINGS 6

Literature Search 7

Employee Interviews 7

Employee Surveys 7

CGC Time Study 8

CGC Volume 10

CVC Inventory Queries 13

Work Sampling Study 14

Steam Sterilizer Load Logs 17

Washer Capacity 18

RECOMMENDATIONS 20

Appendices

Appendix A — CSS Afternoon Job Responsibilities 21

Appendix B — CGC Time Study Data Collection Sheet 22

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Appendix C — CGC Time Study Analysis 23

C.1—Sample Size 23

C.2 — CGC Tray and Wrap Time Standards 24

C.3 — Worked Time and FTE Calculations 25

Appendix D — Work Sampling Study Data Collection Sheet 26

Appendix E — Employee Survey 27

Tables and Figures

Table 1: CGC Workload Breakdown, By Task 9

Table 2. Average CGC Items per day by Item Type 12

Table 3. CGC Time Commitment per day 12

Table 4. CVC OR Expansion Projection 13

Table 5. CVC Non-OR Expansion Projection 14

Table 6. Work Sampling Study Results 15

Table 7. Workload Breakdown, by Client 16

Table 8. Minitab Output for T-Test of Sterilizer Load Logs 17

Table 9. Washer Capacity Data 18

Figure 1. CGC Instrument Breakdown 10

Figure 2. CGC Time Study Validation Data 11

Figure 3. Workload Distribution, by Client 16

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EXECUTIVE SUMMARY

Central Sterile Supply (CSS) is responsible for the decontamination and sterilization ofinstruments and equipment throughout the University of Michigan Hospital Systems (UMHS)and outside clinics. In mid-April, the Cancer and Geriatrics Center (CGC) will be doubling isoperating room capacity. In addition to this, the new Cardiovascular Center (CVC) will beopening. We have been asked to assess the impact of these expansions on CSS. Our client,Karen Bett, the CSS manager, requested our assistance in determining whether the CSSafternoon shift will be able to handle the increased workload that will result from these additions.She is also concerned with the current staffing level of four employees and their ability to handlean absence.

To adequately address these requests, our project team has performed the following analysis onthe afternoon shift:

• Performed a literature search• Performed interviews and surveys (4 employees and 1 manager)• Performed a CGC time study (15 days)• Analyzed CGC and CVC inventory queries (6 months each)• Performed a work sampling study (21 days)• Analyzed Sterilizer load logs (11 days)• Analyzed washer logs (3 months)

These analyses have provided us with the workload distribution for the afternoon staff, supportfor afternoon staffing decisions, and an improved understanding of the work performed for theCGC as well as projected expansions of CGC and CVC.

The literature search provided us with background information on procedures and time standardsfor hospital sterilization. We reviewed past studies performed within CSS from which weobtained the task breakdown of the afternoon shift, a methodology for conducting work samplingstudy, and general information on CSS.

The interviews and surveys provided a qualitative measure of the current workload and theability of CSS to handle the expansion. The employees feel overworked, especially when anemployee is absent. However, all workers said they were able to finish their work, even in theevent of an absence. The employees feel that the workload is evenly distributed among them.

Based on the CGC time study, we developed time standards for the decontamination andassembly of CGC trays and the cleaning and packaging of CGC wraps and instruments. We alsoused the CGC time study to develop an initial estimate of the amount of time spent on the CGCworkload. Combining this information with an inventory query of the CGC we were able tocalculate the current CGC workload in terms of full time equivalents (FTE), as well as predictthe future workload following the expansion of the CGC. When the CGC capacity doubles, wepredict that CSS will require an additional 0.5 FTE.

The CVC inventory queries provided us with the current work that CSS performs for the CVC.This data was used to determine the workload in CSS that arrives from the CVC operating rooms

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(OR) and electrophysiology lab. These queries also provided expansion data for the CVC. Weused this data to determine the impact that the expansion of CVC will have on the current dayshift staff. We expect expansion of the CVC will require an additional 0.5 FTE on the day shift.

The purpose of the work sampling study was to provide a breakdown of the afternoon shift bytask, client, and shift time, as well as a distribution of the workload, by job. The most significanttasks on the afternoon shift were Decontamination and Packaging Instruments. The workloadwas not evenly distributed across the four jobs performed in CSS.

The analysis of the sterilizer load logs allowed us to examine whether there was a backup inwork when an employee was absent. We defined a backup as a sterilizer load that entered thesterilizer during the afternoon shift, but didn’t exit until after 11:00pm, when the midnight shiftstarts. The results showed there was no statistically significant difference in workload backupwhen there were three versus four employees working.

The washer capacity results showed the two CSS washers will just barely be able to handle theincreased workload after the increase of the CGC. This is under the assumption that the CGCloads begin at 5pm, which does not typically happen. Our data supports the purchase of anadditional washer.

Based on all of our analyses we have concluded the following:• CSS will require an additional FTE to handle the CGC and CVC expansions• CSS should staff a “swing” shift employee to handle both expansions• A third washer will be necessary to handle the additional decontamination workload from

the CGC expansion• The CSS staff and manager should discuss and review the workload distribution

While completing our project, we observed several issues that could be points of interest for afuture study of CSS. First, our decomposition of the decontamination task yielded a significantnumber of “other” responses during our work sampling study. We recommend that for anyfuture study of CSS, the decontamination task breakdown that we chose should be reevaluatedand revised so as to reduce the number of “other” responses. Second, we feel that a morecomprehensive client list should be considered for any future work sampling study. Again, weobserved a lot of “other” responses for this category on our work sampling study data collectionsheet. A more comprehensive client list could reduce the number of “other” responses. Finally,we recommend that a staffing analysis of CSS should be performed following the CGC and CVCexpansions. This would reveal if CSS is adequately staffed to handle the workload of theexpanded clients.

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INTRODUCTION

The University of Michigan Health System (UMHS) Cancer and Geriatrics Center (CGC) andthe Cardiovascular Center (CVC), clients of Central Sterile Supply (CSS), will be addingoperating rooms which will increase the workload within CSS. To accommodate theseincreases, CSS will be doubling its sterilization capacity by April, 2006. Therefore, they wouldlike to know if the current staffing level can handle this growth. To assess this problem, CSSasked us to analyze the current afternoon shift and to provide staffing recommendations. Theclient is also interested in knowing the significance of the current CGC current workload throughthe development of time standards.

Focusing on the afternoon shift, our team has conducted employee interviews and surveys, a timestudy, a work sampling (“beeper”) study, inventory queries, and load log analyses. This reportpresents our findings and recommendations concerning the current workload of the four CSSjobs (Appendix A) and the breakdown of CSS workload by client. Additionally, we havedeveloped a forecast of the staffing requirements for CSS following the expansions of the CGCand CVC.

GOALS AND OBJECTIVES

To provide recommendations for current staffing needs this project has accomplished thefollowing:

• Determined impact of projected growth from the CGC and CVC on afternoon staffing• Developed time standards for CGC trays• Determined CSS workload distribution by client, task, and job.

To recommend changes to address these concerns, we:• Studied the CSS afternoon shift employees and operations by collecting and analyzing

qualitative and quantitative data• Obtained and analyzed data from past studies

BACKGROUND

CSS services the main UMHS operating rooms, the CGC, the CVC, and various other clinics andoutside sources, such as St. Joseph’s Mercy Hospital. The CSS staff decontaminates, prepares,assembles and sterilizes various medical materials. These materials include instrument trays,basins, individual instruments, and linens. Additionally, CSS stocks and maintains arrest cartswhile utilizing the concept of event-related sterility practices and providing pasteurizationservices.

In April of 2006, the CSS will be doubling its sterilization capacity by adding two additionalfloor load steam sterilizers, and one cart and carriage unit. This expansion will likely impact theability of CSS to handle the projected growth from the CGC and the CVC by reducing wait timeand increasing the number of trays that can be sterilized. Both departments will be addingoperating rooms; six in the CVC and one in the CGC. The CVC will also be eliminating tworooms, so there will be a net addition of four CVC rooms.

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Appendix A shows the current breakdown of the four afternoon jobs. If an employee is absent,the remaining three employees must complete the responsibilities of all four jobs. Tocompensate for the absent employee, the job responsibilities are modified so that three peoplecan perform them. One of the purposes of this project is to provide a solution to this staffingconcern.

Key Issues

The key issues that drove the need for this project included:• The CSS manager felt that her understanding of afternoon operation was incomplete.• The CSS manager did not know what percentage of afternoon work came from each

client.• The CSS workers felt that they were understaffed. This feeling was exacerbated by

absenteeism.• The CSS manager thought that additions to the CGC and CVC may require additional

afternoon staffing.

Project Scope

The project scope included:• Analysis of staffing needs for afternoon shift (3:00pm — 11:30pm)• Recommendations for current staffing concerns• Analysis of workload by client, task and job• Determination of impact of CGC and CVC expansion on staffing needs

This project did not include:• Analysis of staffing needs for the morning or evening shifts, with the exception of the

CVC expansion• Recommendations for OR, CGC, CVC or other clients• Analysis of any process that does not take place in the CSS• Changes to tasks and workflow• Recommendations concerning storage, equipment, or human factors solutions• Analysis of expansion in areas other than CGC and CVC

PROJECT APPROACH AND FINDINGS

We began data collection by observing the daily processes of CSS and interviewing the CSSafternoon shift employees to gain experienced opinion of the current workload. Initialobservation allowed us to formulate a clear set of tasks on which to collect data for the time andwork sampling studies. We also performed a literature search to identify tasks in the CSSprocess. Our coordinator, Sheri Curnes, suggested that the most appropriate data collectionmechanisms for our project were a time study and a work sampling (“beeper”) study.

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Literature Search

Background

We conducted a literature search on past studies of the CSS at UMHS. Our coordinator providedus with several reports, including a student project similar to ours, completed in 2003. Our clientalso presented us with a document detailing the CSS job responsibilities (Appendix A) as well astime standards for the CVC trays.

Findings

This literature search provided an early understanding of the CSS process. We also used thesearch to develop a methodology for our work sampling study. This technique was used by theprevious CSS project group.

Employee Interviews

Background

Next, we interviewed key members of the CSS afternoon shift staff. We spoke to all afternoonworkers as well as the afternoon shift manager. Our questions were focused on the currentstaffing level and the manageability of the workload.

Findings

Based on our interviews we found the following:• The CSS afternoon shift employees believe that they are currently understaffed• The employees feel that absenteeism results in stressful workloads• The afternoon shift employees perceive that they frequently operate with only three

employees

From these findings we developed data collection methods to quantify the status of the afternoonshift. We focused our data collection on quantifying the current workload of the afternoon shiftstaff to determine if the staff could handle their tasks.

Employee Surveys

Background

We distributed a survey to the CSS staff that assessed their perception of the current workload.The questions included an assessment of the current workload distribution, and their ability tocomplete tasks when there were only three people working. The survey can be found inAppendix E.

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Findings

All employees answered that they felt overworked, both when there were three and fouremployees working. The majority of responses said that the busiest job is Job 1 and the busiesttime of day is 3-7pm (the first half of the shift). Three of four employees said that they alwaysfinish their work when one employee is absent. Finally, all employees felt that the workload wasdistributed evenly among jobs.

CGC Time Study

Background

Our time study of the CSS workload coming from the CGC began on Thursday, February 9,2006 and concluded on Tuesday, March 7, 2006. With the help of the CSS staff, we broke downthe CGC workload into five key tasks: soiled pickup, decontamination, drying, assembly, andcleaning and packaging. This task list covers all of the CGC-related work performed by CSS.Every day, one CSS employee picks up a load of trays and instruments from the CGC. Thequantity and assortment of unique trays and instruments varies from day to day (Appendix B).The CSS afternoon shift staff acted as our study participants in the CGC time study. Each day,the employee in charge of the CGC workload wrote down the start and end times of the keyCGC-related tasks. They recorded this information on our CGC Time Study Data CollectionSheet (Appendix B). Over the four-week period, 19 days of data were collected. Four days ofdata were dismissed due to incomplete or incorrect collection sheets, resulting in a final samplesize of 15 days.

To assist the CSS staff and validate the accuracy of the data, we observed 24 hours of datacollection. This observation included two full eight-hour shifts. During observation, wecollected data to validate data collected by the CSS staff.

Findings: CGC trays take 22.50 minutes to decontaminate, dry, and assemble, on average. CGCwraps and instruments take 4.33 minutes to clean and package, on average.

For our time study of the CGC, we observed 15 days worth of data. During this time, CSSreceived 68 trays and 18 wraps from the CGC. Trays are decontaminated, dried, assembled, andsterilized by CSS. Wraps, which are usually single instruments, arrive at CSS clean, and areonly wrapped and sterilized.

Our time study of the CGC workload yielded the following results:• CSS receives 4.53 trays per day from the CGC, on average• CSS receives 1.20 wraps per day from the CGC, on average• CSS spends 123.39 minutes per day on CGC specific work, on average

Table 1 shows the breakdown of the total time spent on CGC specific work, by task. A completeanalysis of the CGC time study results is located in Appendix C.

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Table 1. CGC Workload Breakdown, By TaskTask Average Time/Day (m) Fraction of Total Time (%)

Soiled Pickup 16.20 13.13Decontamination 54.06 43.81

Drying 6.87 5.56Assembly 37.07 30.04

Cleaning and Packaging 9.20 7.46Total Time on CGC 123.39 100.00

According to the time study data, one CSS employee spends about 2 hours and 3 minutes per dayon work exclusively for the CGC during the afternoon shift. Based on the CGC time studyalone, and assuming that the time worked by a CSS employee is 6.52 hours per day, the currentCGC workload requires 0.32 full time equivalent employees.

Our simultaneous analysis of the volume of trays and instruments received by CSS from theCGC showed that some of the CGC-related workload was not accounted for by the CGC timestudy. Specifically, only the significant trays and instruments sent to CSS from the CGC duringthe time study were recorded. Individual instruments made up the majority of the unrecordedvolume. This means that the CGC time study, by itself, would slightly underestimate the actualCGC-related workload. Consequently, we primarily used the time study data to develop timestandards for processing CGC trays and instruments. Then, by combining these time standardswith our CGC volume analysis (detailed in the following section), we were able to derive a moreaccurate estimate of the current CGC workload.

Based on our CGC time study, we developed the following time standards for CGC-relatedtasks:

• The average time required to decontaminate, dry, and assemble a CGC tray is 22.50minutes

• The average time required to clean and package a CGC wrap or individual instrument is4.33 minutes

Neither of these time standards includes soiled pickup time. On average, CSS spends 16.20minutes per day picking up trays and instruments from the CGC. This is the average time for asingle pickup.

Recommendations

Currently, CSS makes a single trip to the CGC to pick up trays and instruments. On most ofthese trips, the carts used for pickup are mostly full, or at least more than half full. Therefore, ifthe quantity of CGC trays and wraps handled by CSS doubles following the expansion of theCGC, two trips to the CGC would be needed to pick up all items. This would add 16.20 minutesto the future workload. Therefore, we recommend that CSS considers using larger carts forsoiled pickup from the CGC. If CSS switches to a cart that can handle the expected increase inCGC trays and instruments, the need for a second trip to the CGC can be avoided.

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We also recommend that time standards developed from our CGC time study should becombined with our CGC volume analysis to calculate the current and projected CGC-relatedworkload of CSS. This will provide a more accurate estimate than using the time study alone.These calculations are described in detail in the following section.

CGC Volume

Background

The CGC volume analysis was performed along with the CGC time study. Our client providedus with CGC records that contained every tray, wrap and instrument set that had been sent toCSS over a six month period, from September 1, 2005 to February 28, 2006. This data was usedto determine the breakdown of CGC trays in CSS and to validate the CGC time study. It wasalso used with the time standards created by the CGC time study to create a more realisticprojection of the CGC expansion.

Findings: To handle the CGC expansion, CSS will require an additional 0.39 full timeequivalent employees.

The breakdown of the major trays from the CGC that go to CSS is shown in the following chart:

Vaginal Speclum2%

Hinged WeitlanderRetractor

5%

6%

Dr. Boyd’s Oto/PlastiBebakey ForcepAdds

1%2%

Laryngeal Blades

B2P Soft Tissue Set(Sondak) 33%

Black Rush Mask13%

Figure 1. CGC Instrument BreakdownSource: Karen Bett, CSS Manager

Minor Gyn Sets2%

Cotton Balls

Towel Clips2%

206 Ne—-Richardsons Set

2% SON Adds—13%

Adson1%

13%

Insulated Richardson’Retractor

V /0

LMA’s7%

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Figure 1 shows the most significant trays and wraps that the CGC sends to CSS. Our totalsample size was 1302 trays and wraps over a six month period which encompassed 111 days.The B2P Soft Tissue Set, otherwise known as the Dr. Sondak’s tray, comprises about one-thirdof all of the CGC trays that CSS sterilizes. The miscellaneous category consists of 60 other traysand wraps that were seen less than 15 total times over the six month period.

The following chart expresses the stratification of the 12 different trays and wraps that wewitnessed over the course of the time study using the six months of CGC data provided to us byour client:

Thompson Retractor Skin Graft Mesher1% 1%

ndBone Marrow B e Marrow Sta

1%Instruments0

,xtraLong instruments

0%

Figure 2. CGC Time Study Validation DataSource: Karen Bett, CSS Manager

Figure 2 validates the fact that our time study captured a representative sample size. Over thecourse of the time study, we witnessed that approximately 70% of all items processed by CSS forthe CGC were B2P Soft Tissue Sets, which is validated by the figure shown above.

The second purpose of the CGC volume analysis was to validate that the volume of trays andwraps that we witnessed in the CGC time study is representative of average daily CGC volume.Table 2 stratifies CGC daily item averages by item type:

Electric Dermatome1%

Skin Graft Set1%

Dr. Boyd’s Oto/PlasticAdds

A 0//0

Minor Gyn Sets4%

Dr. Newman’sRichardsons Set-

6%

SON Adds70/I /0

/B2P Soft Tissue Set(Sondak)

73%

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Observed Tray 4.55Unobserved Tray 0.10Observed Wrap 0.57Unobserved Wrap 6.51

Total: 11.73Sample Size: 6 months

Source: Karen Bett, CSS Manager

The average number of total items (which includes trays, wraps and individual instruments) perday was 11.73. Looking solely at trays, there was an average of 4.65 trays per day, 3.77 ofwhich are B2P Soft Tissue Sets. This also suggests that the data collected concerning number oftrays in the CGC time study is valid, as the average number of trays per day was 4.53. However,we did not observe nearly as many wraps as we did in this data. This is attributed to the fact thatwraps require only cleaning and packaging, and hence were not a major time commitment for theafternoon staff, so they remained largely unrecorded in the time study. Therefore, our client feltthat it was acceptable to apply the time standards for the few wraps that we did observe to thenumerous unobserved wraps. Applying these time standards (22.50 mm per tray and 4.33 mmper wrap) and assuming a capacity increase of the CGC of 100%, the following table wasderived:

Table 3. CGC Time Commitment per dayAvg. Daily Time

Expenditure (mm)Observed Tray 104.59Observed Wrap 2.46Unobserved Wrap 28.20

Total: 135.26Soiled Pick Up (mm): 16.20

Total CGC time per day: 151.46Time Study Prediction: 123.39

Difference: 28.07CGC Projection: 302.91

.. . .. .

Recohrnend tion 0 39acdit,ona! FTESample Size: 6 months

Source: Karen Bett, CSS Manager

Table 3 shows that the time currently spent on CGC per day is more near 151 minutes instead of123 minutes. This is a difference of nearly 30 minutes and is explained by all of the wraps thatwere not recorded by the CGC time study. With the CGC expansion, it appears that anadditional 0.39 full time equivalent employees will be required to cover the expansion

Recommendation

Our recommendation for CSS is to add 0.50 FTE to the afternoon staff to cover the expansion inthe CGC.

Table 2. Average CGC Items per day by Item Type# of Trays

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CVC Inventory Queries

Background

The new CVC area is expanding current operations in both its OR and Non-OR operations. Thenumber of CVC OR carts sent to CSS will increase after this expansion. These carts aredecontaminated and wrapped before they are sent down, so the only remaining step in CSS willbe sterilization. The most important increase in the CVC Non-OR is taking place in theElectrophysiology lab (EP).

Mary Duck, Senior Management Consultant, provided us with data concerning the CVC ORexpansion. This data contained the current and projected number of cases that will take place inthe CVC OR.

Our client provided us with inventory queries that were used to quantify the current CVC Non-OR workload that takes place in CSS. These inventory queries consisted of six months of datafor the two trays that CSS handles for the EP lab that will be affected by the expansion. Thisdata was used with existing time standards provided by our client to estimate the currentworkload in CSS coming from the CVC Non-OR. Daphne Betley, Technical Coordinator, EPlab, then provided us with an estimated expansion that will be taking place in the EP lab. Thecalculated current workload was then used with this expansion estimate to estimate the futureworkload for CSS after the expansion of the CVC.

Findings: The expansion in the CVC OR and Non-OR operations will require a total addition of0.30 employees to the CSS day shift staff

The results for the OR portion of the CVC expansion are shown in Table 4:

Table 4. CVC OR v11r ProjectionCurrent Time Spent on CVC (mm - - - Projected Time Spent on CVC (mm)

M T W Th F Total M T W Th F Total

No. of Carts 0.72 0.84 1.02 0.81 0.81 4.20 0.96 1.11 1.31 1.06 1.15 5.60Total (hrs) 0.33 0.34 0.50 0.31 0.35 1.83 0.49 0.51 0.59 0.47 0.47 2.53FTEs/week

_________________________________

0.05

_________________________________

0.07I 0.02 Additk4haGFTE I

Source: Mary Duck, Senior Management Consultant

These results are based on three assumptions:1. An average of ten minutes of CSS manual labor is required per cartload (as estimated by

our client)2. Three trays required per case in the CVC OR (as estimated by our coordinator and Mary

Duck)3. Ten trays per cartload come down from the CVC OR (as estimated by our client)

Table 3 suggests that the CVC OR expansion will require 0.02 additional FTE’s. This isexpected because the only CSS responsibility for the CVC OR carts is to retrieve them from the

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elevator, stamp them, place them in the sterilizer and then return them to the elevator whenfinished.

The results for the Non-OR portion of the CVC are shown in Table 5:

Table 5. CVC Non-OR Expansion ProjectionTRAY, EP CSU

Current CSS time spent Projected CSS Time SpentAVG per week (hrs) 2.02 2.19FTE’s 0.06 0.06RecOthEnentIaic 0.00 FTE

TRAY, PACEMAKER EPCurrent CSS time spent Projected CSS Time Spent

AVG per week (hrs) 19.12 28.67FTEs 0.54 0.82Recommepddhoi 028 FTE

Sample size: 6 monthsSources: Karen Bett, CSS Manager and Daphne Betley, Technical Coordinator, EP Lab

Table 5 suggests that the CVC Non-OR expansion will increase CSS workload by 0.28 full timeequivalents. Combined with the CVC OR expansion, the total workload increase will be 0.30full time equivalents. Currently, the afternoon shift is not responsible for the CVC. If the CVCrelated work remains a job for the day shift, the afternoon shift will not be impacted when thisworkload increases.

Recommendation

Our recommendation for CSS is to add 0.50 FTE to the day shift staff to cover the expansion inthe CVC. Our overall staffing recommendation will be covered in greater detail in the finalrecommendations section.

Work Sampling Study

Background

The work sampling study began on March 08, 2006 and concluded on March 28, 2006. Thework sampling study consisted of providing the afternoon staff with beepers that went off atrandom times at the rate of five beeps per hour. When the beeper sounded, the staff markeddown which task they were performing, for which client, and during which half of the shift thebeeper sounded. They recorded this on the Beeper Study Data Collection Sheets that weprovided (Appendix D). This study was useful in determining the significant tasks and clients ofthe afternoon shift. This data was also used to determine the equality of the current jobdistribution as defined in Appendix A.

During the work sampling study, we attended at least eight hours of observation per week. Thisobservation time was used to ensure that the employees were performing the beeper study

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correctly, to answer any questions that they had and to observe any variations in workloadthroughout the day.

The main purpose of the work sampling study was to provide our client with informationregarding operations on the afternoon shift. Since our client primarily works during the dayshift, she wanted more complete information pertaining to the tasks, major clients, and workloaddistribution from the afternoon shift.

Findings: The breakdown of the CSS afternoon shift by task, client, and time of shift are shownbelow.

Table 6 is a summary of the results from the work sampling study by client, task, and shift time.Table 7 shows the total percent of time spent on each client during the afternoon shift.

— contamination

-Pre-cJIeaJ3’Scv7ic

Table 6. Work Sampling Study Results

Sample Size: 51Source: Work Sampling Study

OutsideTask Job % of Total lime OR CGC Clinics Other 3- 7pm 7-1 1pm 3-7pm 7-llpm

Anser Phone/Intercom Al 1% 40% 0% 24% 36% 2% 1% 76% 24%sseiiibI&Nr Trays or Sets 2 5% 0% 60% 4% 36% 0% 9% 5% 95%

reaks/PersonaI lime All 6% 0% 0% 0% 100% 3% 8% 26% 74%Catching 4 6% 8% 2% 0% 90% 2% 11% 16% 84%ChedlRestock Inventory All 2% 24% 0% 0% 76% 1% 2% 35% 65%Clean DeIiy 1 0% 0% 0% 44% 56% 0% 1% 11% 89%CSS Pervork BidocaI Indicator Reading 14 6% 39% 5% 14% 41% 6% 5% 54% 46%

19% —I

3 4% 1% 15% 0% 24% 2% 7% 22% 78%- 3 2% 0% 62% 0% 38% 4% 1% 83% 17%

-Lng 3 1% 0% 10% 0% 90% 1% 1% 38% 62%-Other 3 12% 25% 1% 0% 74% 11% 13% 46% 54%

Fd&PeUnen 1 4% 27% 0% 72% 1% 6% 1% 82% 18%Loan Gas Sterilizer Cart 4 4% 15% 1% 61% 22% 7% 1% 90% 10%Loan Steam Sterilizer Cart 1 3% 59% 7% 24% 10% 4% 2% 66% 34%LoacI/L.kdoad Dtr 4 0% 20% 0% 60% 20% 0% 0% 40% 60%NsceNaneous All 4% 0% 0% 5% 95% 4% 5% 44% 56%Pakage Instruments 2 25% 0% 2% 0% 98% 26% 24% 53% 47%Pasteutization 3 1% 0% 0% 55% 45% 0% 1% 36% 64%Put Cart on Eleiator 1,4 2% 90% 5% 5% 0% 2% 2% 50% 50%SofedPick-L. 3 7% 11% 23% 0% 66% 13% 0% 98% 2%Take Cart off Elevator 1,4 2% 97% 0% 0% 3% 2% 2% 52% 48%Unload Gas StenhzerCart 4 0% 50% 0% 50% 0% 0% 0% 100% 0%Unload Steam Sterilizer Cart 1 3% 64% 4% 20% 12% 3% 3% 52% 48%

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Table 7. Workload Breakdown

Client ContributionOR 19%CGC 8%Outside 9%Other 64%

As shown in Table 6, Decontamination and Packaging Instruments consume the majority of theafternoon shift workers’ time. These two tasks are performed by Job 3 and Job 2, respectively.Most tasks are distributed evenly over the shift with the exception of “Assemble/Wrap Tray orSets” and “Catching,” which are done primarily on the second half of the shift, and “Soiled-pickup,” which is done primarily on the first half of the shift. Table 6 shows that the majority of theworkload on the afternoon shift comes from the “Other” category, which includes the outsideclinics and other hospitals.

Workload Distribution

Using the data collected during the work sampling study, a workload distribution was created todetermine if the jobs were evenly distributed, shown in Figure 3. The distribution shows that thejobs are not completely evenly distributed, with Job 2 and Job 3 having a slightly higherpercentage of the work load. When one employee is absent, the tasks of Job 1 and Job 4 areperformed by one person. The specific tasks for each job can be seen in Appendix A.

Figure 3. Workload Distribution, by Client

35%

Workload Distribution

30%

Cu0

25%

20%

o 15%C,

a)

a)0.

10%

5%

0%

Jobi Job2 Job3 Job4

Job Number

16

The work sampling study showed that Job 2 and Job 3 (Packaging Instruments andDecontamination) consumed the majority of the afternoon shift workers’ time. This is alsoreflected in the workload distribution, which showed that Job 2 and Job 3 have the highestpercentages of the total workload. This quantitative data contradicts the qualitative data obtainedfrom the employee surveys, which showed that the majority of the workers on the afternoon shiftfelt that Job 1 was the most time consuming job, and that the workload was evenly distributed.

Recommendations

The job descriptions, shown in Appendix A, were determined by the employees and the CSSmanager. Since the results of the qualitative analysis from the employee surveys do not supportthe quantitative results from the work sampling study, we recommend the afternoon shiftworkload distribution be discussed and reviewed. This could help to determine the source of thisdiscrepancy and whether or not the current job descriptions need to be altered, as they may beoutdated. This review of the workload distribution will also be necessary prior to any FTEaddition.

Steam Sterilizer Load Logs

Background

To quantify the effects of absenteeism, we performed analysis on the steam sterilizer load logs.Over the last few weeks of observation, we obtained and analyzed sterilizer load logs from CSSto check the amount of backup loads that resulted on days with an employee absent. Since theafternoon shift is from 3:30pm to 11:00pm, a “backup” was defined as a sterilizer load that wentin on the afternoon shift, but came out after 11:00pm, which would mean the midnight shiftwould be responsible for unloading.

Findings: We did notfind a backup of sterilizer loads due to absenteeism.

A two-sample T-test was run on the load log data to determine if there was a statisticallysignificant difference in the number backups when there were three versus four employees. Theresults of the t-test are shown in Table 8.

Table 8. Minitab Output for T-Test of Sterilizer Load Logs

Two-sample T for Late Finish

Staff N Mean StDev SE Mean3 13 1.692 0.855 0.244 51 1.45 1.05 0.15

Difference mu (3) - mu (4)Estimate for difference: 0.24132795% CI for difference: (—0.336519, 0.819174)T-Test of difference 0 (vs not ) : T-Value = 0.87 P-Value 0.396 DF = 22

17

Table 8 shows there was no statistical difference between the two samples using a 95%confidence interval (p-value = 0.396). While the sterilizer loads generally went in later duringthe shift when one employee was absent, there is no workload backup when only 3 employeesare present, based on this data.

Recommendations

Our analysis covered 13 days with only three people on staff. Three of these days wereconsecutive. The results suggest that CSS staff is able to cover their four jobs in the case of shortterm absenteeism.

Washer Capacity

Background

We performed an analysis on the two washers used in the CSS to assess their ability to handlethe CGC expansion. We found that about 20% of the loads that go through the washers everyday during the afternoon shift are CGC-related. This number was based on staff estimates of thenumber of CGC-related loads. We combined this estimate with our data gathered from thewasher logs.

Findings. The washers within CSS can only handle the CGC expansion if CGC loads arestarted early enough in the shift

We found that the two washers currently have a combined daily usage during the afternoon shiftof 8.6 hours. Table 9 shows the data from the analysis on these logs.

Table 9. Washer Capacity Data

% washer loads CGC 19.51Average wash time 38.21Average loads/day 13.45Hours/day total 8.57Hours/day on CGC 1.67Hours/day non CGC 6.90Hours/day CGC after expansion 3.34Hours/day total after expansion 10.24

The average wash time is 38.2 minutes. We expect that the washers will be used a combined10.2 hours during this shift following the CGC expansion. The amount of available time to usethe washers during this shift is 12 hours, because we must factor in the restriction that CGCitems do not enter the washers until after 5pm. Our calculation shows that the expansion withinCGC can be handled by the washers (10.2 < 12).

18

Recommendations

Our results suggest that the two washers have the capacity to handle CGC-expansion, but only inthe case that the loads are started early enough in the shift. An increase in CGC-related loadswill likely result in a later start time for washing, making the two washers unable to handleincreased loads.

19

RECOMMENDATIONS

The following section provides our overall recommendations to CSS based on all of ouranalyses.

Regarding the expansion of the CGC, we recommend the following:• CSS should consider using larger carts for soiled pickup from the CGC. This could

potentially reduce the need to make two trips per day, reducing the average time spent onCGC-related work by 16.20 minutes per day.

• CSS should staff an additional 0.50 full time equivalent employees on the afternoon shiftto handle the expansion of the CGC.

• CSS should install a third washer to accommodate the expected increase in CGC-relatedwork.

Regarding the expansion of the CVC, we recommend that CSS should staff an additional 0.50full time equivalent employees on the day shift to handle the expansion of the CVC.

Regarding the overall staffing increase, we recommend the following two alternatives:• Add a “swing” shift employee (one full time equivalent) that would work the second half

of the day shift and the first half of the afternoon shift.• Add a full time equivalent to either the day or afternoon shift.

The first alternative is preferred for the following reasons:• About half of the additional workload is for the day shift (CVC), and the other half is for

the afternoon shift (CGC)• The first half of the afternoon shift (3-7pm) is currently busier than the second half (7-

11pm)

Regarding the staffing effects of employee absenteeism, we recommend the following:• Short term expected and unexpected absenteeism (1-4 days) should not require additional

staffing for the following reasons:o Occasional absenteeism does not create work back-ups or incomplete worko Work load is more stressful, but manageable

• Long term expected and unexpected absenteeism (more than 4 days) should requiretemporary or “on call” staffing because the more stressful workload should not remainuninterrupted for an extended period.

Regarding the current CSS workload distribution, we recommend that the current taskdistribution, by job, should be discussed and reviewed by the CSS staff and managers.

20

Appendix A — CSS Afternoon Job Responsibilities

UNIVERSITY OF MICHIGAN HEALTH SYSTEMSCENTRAL STERILE SUPPLY

AFTERNOON JOB RESPONSIBILITIES

JOB 1 STEAM STERLIZA TIONPROCESS ALL STEAM ITEMS THAT COME INTO CSS. MONITOR STEAMBIOLOGICAL AND LOG RESULTS. FOLD & WRAP ITRADURAL SHEETS(QUOTA ON SHELF 150) & BIOPSY TOWELS (QUOTA ON SHELF 150).CHECK GAS MACHINES AT ONE-HOUR INTERVALS TO MAKE SURECYCLE HAS GONE INTO AERATION. AT THE FIRST SIGN OF A PROBLEM,MAINTENANCE AND A SUPERVISOR SHO ULD BE NOTIFIES. CALLPAGING 936-6267 AND HAVE THEM PAGE MAiNTENANCE STAT IF YOUDO NOT GETA RESPONSE, CONTACTAFTERNOON SUPERVISOR (PAGER#2574). IF STILL NO RESPONSE, CALL KARENATHOME 981-5342.

JOB 2 PACKAGE AND PROCESS INDIVIDUAL INSTRUMENTSINVENTORY AND PROCESS INDIVIDUAL INSTR UMENTS

JOB 3 DECONTAMINATIONPICK UP MOTT & TA UBMAN SOILED INSTR UMENTS DAILY. SORJ SONICAND SEND THRO UGH THE WASHERS. SEND THRO UGH NEWINSTR UMENTS AS NEEDED. CLEAN DOLLIES, CO UNTERTOPS ANDTABLE TOPS. KEEP AREA NEAT AND CLEAN A TALL TIMES. CLEAR PASSTHRO UGH WINDOW AT THE END OF YOUR SHIFT

JOB 4 AFTERNOON GASRUN GAS LOAD. CATCH CLEAN INSTRUMENTS. HANG AND PACKAGEPASTEURMA TIC. DO CGC TRAYS. COVER ABSENCES. PICK UP CLEANGAS & STEAM ITEMS IF 10 HOUR SHIFT PERSON IS ABSENT

10-HOUR SHIFT PERSON PICKS UP AFTERNOON CLEAN GASANT) STEAM ITEMS.

JOB ASSIGNMENTS DURING STAFF ABSENCES:

#1, #2, or #3 is absent, job covered by #4.II. If down 1 staff:

• #1 Steam, gas, clean pick-ups & catching• #2 Instruments, pasteurizer, CGC & take up respiratory• #3 Soiled pick-ups & put up instruments. Pick up CGC trays.

21

CE

NT

RA

LS

TE

RIL

ES

UP

PL

YC

GC

TIM

EST

UD

Y

Activity

Nam

eor

Description

Start

End

Start

End

Notes

*L

isteach

traysep

arately

Key

forA

ctivities:S

P-

SoiledPickup

D-

Decontam

inationD

RY

-D

ryingA

-Assem

blyC

P-

Cleaning

andP

ackagingS

-Sterilization

Date:

Job

#:

#on

staff:

ASSE

MB

LY

ON

LY*

AC

TIVITY

TIM

EIN

TE

RR

UPT

ION

C—C2C

/U

Appendix C.1 — CGC Time Study Sample Size

CGC TIME STUDY RESULTS

SampleSam’èize = 15 00 days 68 00 trys 1800Average = NA 4 53 trays/d 1 20 wraps/ctStd. dev. = NA 1.30 trays/d 1.32 wraps/d

Soiled PickupSample size = 15.00 daysAverage = 1620 m/dStd. dev. = 2.88 m/dMax= 21.00Min= 10.00

DECONTAMINATION Washer TimeSample size = 15.00 days 68.00 trays Sample size 148.00 loadsAveie = 92 27 m/d 20 35 rn/tray Average = 38 21 rn/loadStd. dev. = 19.88 m/d 7.31 rn/tray Std. dev. = 1.54 rn/loadMax = 135.00 m Max = 43.08 mMm = 60.00 m Mm = 36.20 m

Decontamination w/o WasherSample Size = 15.00 days 68.00 traysAvrØge 54 06 m/d 11 92 rn/frayStd. dev. = 19.94 m/d 5.57 rn/trayMax = 96.79 mMin= 21.79m

DryingSample size = 15.00 days 68.00 traysAverage = 6 87 m/d 1 51 rn/trayStd. dev. = 3.46 m/d 0.88 rn/trayMax= 13.OOmMm = 0.00 m

23

Lw

l)LwLw

c-)C)

C)

.—

ASSE

MB

LY

Sondak

S0nA

DD

Sam

plesize

=15.00

days68.00

traysS

ample

size=

60.00trays

Sam

plesize

=2.00

traysA

verag

e$41

07rn/d

9m

/tray

Average

=8

87rn/tray

Average

=4

50rn/tray

Std.

dev.=

16.34m

Id3.27

rn/trayS

td.dev.

=3.24

rn/trayS

td.dev.

=0.71

rn/trayM

ax=67.00

rn16.00

rnM

ax=16.00

mM

ax=5.00

mM

iri=

23.00m

3.00m

Mm=

3.00m

Miri

=4.00

mD

r.B

oyd’sO

toP

lasticM

inorgynS

ample

size=

5.00trays

Sam

plesize

=1.00

traysA

verage=

13.00rn/tray

Average

=10.00

rn/trayS

td.dev.

=4.47

rn/trayS

td.dev.

=N

Arn/tray

Max=

15.00rn

Max=

10.00rn

Mit,

=5.00

mM

iii=

10.00m

CL

EA

N&

PAC

KA

GE

Skin

Graft

Set

Dr.

New

man

Rich

ardso

n’s

Sam

plesize

=15.00

days18.00

wraps

Sam

plesize

=3.00

wraps

Sam

plesize

=4.00

wraps

Average

=5

20m

/d4

33

rn/wrap

Average

=4

67rn/w

rapA

verage=

200

rn/wrap

Std.

dev.=

6.41rn/d

1.75rn/w

rapS

td.dev.

=1.53

rn/wrap

Std.

dev.=

0.00rn/w

rapM

ax=

18.00rn

7.00rn/w

rapM

ax=

6.00rn

Max

=2.00

mMm

=0.00

rn2.00

rn/wrap

Mm=

3.00rn

Mm=

2.00m

Skin

Graft

Mesher

Derm

atome

Sam

plesize

=2.00

wraps

Sam

plesize

=2.00

wraps

Average

=5.00

rn/wrap

Average

=5.50

rn/wrap

Std.

dev.1.41

rn/wrap

Std.

dev.=

0.71rn/w

rapM

ax=

6.00rn

Max

=6.00

mMm

=4.00

rnMm

=5.00

rnE

xtraL

ongIn

strum

ents

Th

om

pso

nR

etractor

Sam

plesize

=1.00

wraps

Sam

plesize

=1.00

wraps

Average

=5.00

rn/wrap

Average

=6.00

rn/wrap

Std.

dev.=

NA

rn/wrap

Std.

dev.=

NA

rn/wrap

Max

=5.00

mM

ax=

6.00rn

Mm=

5.00m

Mm=

6.00m

Bonem

arrowIn

strum

ents

Bonem

arrowS

tand

Sam

plesize

=2.00

wraps

Sam

plesize

=3.00

wraps

Average

=5.50

rn/wrap

Average

=4.33

rn/wrap

Ski.

dev.=

0.71rn/w

rapS

td.dev.

=2.52

rn/wrap

Max

=6.00

rnM

ax=

7.00m

Mm=

5.00rn

Mm=

2.00m

Appendix C.3 — Worked Time and FTE Calculations

TOTAL TIMESample size = 15.00 days 65.00 traysJeraJ = 12339 m/d 22 50 m/tray*Std. dev. = 26.94 mId 6.52 rn/trayMax= 151.79mMm = 85.79 rn

*This does NOT include Soiled Pickup time

CGC Workload DistributionSoiled Pickup 13.13 %Decontamination 43.81 %Drying 5.56 %Assembly 33.28 %Cleaning & Packaging 4.21 %

Worked TimePTO = 21.33 h/mo 256.00 h/yrPT = 40.00 h/wk 2080.00 h.yrWT = 35.08 h/wk 1824.00 h/yr

7.02 h/dBreak time = 0.50 h/dACTUAL WT 652 hId 39092 m/d

FTE CALCULATIONCGC work = 032 FTE

25

BE

EP

ER

STU

DY

DA

TA

CO

LL

EC

TIO

NS

HE

ET

Break

End

Tim

e:

Date

ofStudy:

#on

Staff:

Break

Start

Tim

e:Job

#:

3:0

0--7

:OO

pm

Outside

Task

OR

CG

CC

linicsO

ther

7:00--1

1:0

0pm

Jj-0-

—0

Outside

OR

CG

CC

linicsO

ther

Answ

erP

hone/Intercom

Assem

ble/Wrap

Trays

orS

ets

Breaks/P

ersonalT

ime

Catching

Check/R

estockInventory

Clean

Delivery

CS

SP

aperwork,

Biological

IndicatorR

eading

Decontam

ination

-Sort

-Pre

-Clean/S

onic

-Loading

Fold/P

ackageL

inen

Load

Gas

Sterilizer

Cart

Load

Steam

Sterilizer

Cart

Load/U

nloadD

ryer

Miscellaneous

Package

Instruments

Pasteurization

Put

Cart

onE

levator

Soiled

Pick-Up

Take

Cart

offE

levator

Unload

Gas

Sterilizer

Cart

Unload

Steam

Sterilizer

Cart

UU

Appendix E — Employee Surveys

Survey of CSS Afternoon Staffing

1. Do you feel overworked?

Do not feel Overworked 1 2 3 4 5 Feel very overworked

Comments:________________________________________________________________

If yes, when do you feel the most overworked (which job and at what time of

day)?

Job: Job 1 Job 2 Job 3 Job 4

Timeofday: 3pm—7pm 7pm—llpm

Comments:__________________________________________________________

2. Do you feel overworked when there are only three employees working?

Do not feel Overworked 1 2 3 4 5 Feel very overworked

Comments:_____________________________________________________________

3. Do you finish your work when there are only three employees working?

Always finish 1 2 3 4 5 Never finish

If no, what do you leave for the next shift?__________________

Comments:_______________________________________________

4. Do you feel the workload is distributed evenly among the jobs?

Yes No

If no, what would you change?

Comments:

_________________________________

Thanks for your time!

27